Patient Biographical Information
Patients 18 and Over
*First Name:     Middle Initial: *Last Name:     Nickname:	*Birthdate:     *Gender:   Male Female  Marital Status: Married Divorced Widowed Single
*Address:   *City:   *State:   *Zip:   *This form is being completed by: Self Spouse Other *If other: *Main Phone:   *Cell Phone:   *Email:    Employer: *Occupation:    Work Phone: Patient's interest in treatment: Patient wants treatment Patient unwilling, but agrees Treatment only if necessary Patient un-cooperative     What is the patients main orthodontic concern? Please list the names of any friends or family currently in the practice: Whom may we thank for referring you to our practice?

Dental History
Dentist Name: Address: City: State: Zip:	Has the patient had an orthodontic consultant or treatment? NoYes If so, when? Check-up Frequency: Once per year Twice per year More than twice a year Never Emergencies only Last Dental Visit:
*Please answer the following questions. (Cannot be left blank.)
NoYes Speech problems/therapy?   NoYes Grind or clench teeth?   NoYes Oral habits (thumb/finger sucking, nail biting)?   NoYes Injury to face, jaw, teeth or mouth?   NoYes Discomfort from teeth or gums?   NoYes Pain, tenderness or noise in either jaw?   NoYes Frequent headaches?   NoYes Neck/shoulder pain?   NoYes Frequent sore throats?   NoYes Excessive bleeding following extractions?   NoYes Trouble associated with previous dental work?	NoYes Brush teeth daily?   NoYes Floss teeth daily?   NoYes Fluoride treatments?   NoYes Mouth breathing?   NoYes Snores during sleep?   NoYes Requires premedication?   NoYes Any missing or extra permanent teeth?   NoYes Apprehensive about dental care?   NoYes Frequently chew gum?   NoYes Periodontal/gum treatment?   NoYes TMJ/jaw joint treatment?
Please provide necessary explanations below:

Medical History
Physician Name: Address: City: State: Zip:	Date of last Physical:   Patient Health: Good Excellent Fair Poor
*Please select YES if the patient has had any of the conditions listed below either now or in the past.
NoYes Rheumatic Fever   NoYes Tuberculosis/Lung Disease   NoYes Pneumonia   NoYes Liver Disease   NoYes Kidney Disease   NoYes Heart Attack/Stroke   NoYes Heart Disease   NoYes Congenital Heart Defect   NoYes Heart Murmur   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Prolonged Bleeding/Transfusion   NoYes Anemia   NoYes HIV/AIDS   NoYes Hepatitis   NoYes Tonsils/Adenoids Removed   NoYes (Women) Are you pregnant?   If pregnant, please give due date	NoYes Cancer   NoYes Family History of Cancer   NoYes Received Radiation Treatment   NoYes Growth Problems   NoYes Endocrine Problems   NoYes Hormone Therapy   NoYes Latex/Metal Allergy   NoYes Nervous Disorders   NoYes Bone Disorders/Bone Loss   NoYes Diabetes   NoYes Seizures/Epilepsy   NoYes Handicaps/Disabilities   NoYes Asthma   NoYes Arthritis   NoYes Treated for Emotional Problems   NoYes Ever Been Hospitalized   NoYes Do you use tobacco in any form? If use tobacco, how much?
If any of the above medical questions were answered 'Yes' , please explain:
Is patient currently under the care of a physician? Please explain:
Are you currently or have you ever taken any bisphosphonate medications for the treatment of bone loss? (ie. Actonel, Boniva, Phosomax, Reclast, etc.) If YES, please explain:
List any other medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:

Spouse's Information
First Name: Middle Initial: Last Name:	Address: City: State: Zip:
Main Phone: Cell Phone: Email:	Employer: Occupation: Work Phone:

Who will be financially responsible for the treatment?	Self Spouse Other

Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:   Middle Initial: *Last Name:	*Address:   *City:   *State:   *Zip:
*Main Phone:   *Cell Phone:   *Email:     Relationship to Patient: Self Spouse Other If other:	Employer: *Occupation:   Work Phone:

Would you like us to provide you with insurance forms? NoYes